Iowa Bans Medicaid Coverage for Trans Healthcare
Section 14 of the HHS funding bill guts gender affirming care
In its latest attack on trans lives, both houses of the Iowa Legislature voted Wednesday to pass House File 1049, the appropriations bill for the Department of Health and Human Services. Included in the bill is Section 14, a prohibition on medicaid reimbursement for “Sex reassignment surgery or associated procedures.” The bill goes on to list hormone replacement therapy (HRT), and any procedure to alter someone’s sex characteristics. Of course, this ban only applies to trans people who receive those procedures; mastectomies, hysterectomies, orchiectomies, and HRT are still covered for cis Iowans. This amounts to a full ban on trans healthcare for Medicaid recipients in Iowa, and could have knock on effects related to how hospitals and other care providers treat trans patients.
This attack follows months after Iowa became the first state in the nation’s history to remove civil rights protections for transgender people, or any protected class for that matter, an action that drew thousands of protestors to what became the largest demonstration ever at Iowa’s capitol. That demonstration didn’t stop the Republican supermajority in the legislature from enacting hate, however. Steve Holt (R-Denison), the bill’s floor manager, said on the record that day that removing trans healthcare from Medicaid was a core motivation behind the broad assault on our civil rights.
This kind of medical discrimination is not new to Iowa. Medicaid was never particularly friendly to trans people, even after we were added to the Iowa Civil Rights Act in 2007. Challenges to Iowa Medicaid’s refusal to cover trans healthcare go back to 2017, and community members successfully overturned the state’s policy of denying coverage in 2019, with the Iowa Supreme Court finding the policy constituted sex discrimination against trans Iowans, as well as violated the equal protection clause of Iowa’s constitution. With those protections now legally questionable, if not entirely removed after the passage of House File 418, Republicans took their chance to reinstate their previous policy.
While February’s civil rights bill saw dozens of Democrats stand up against its injustice, only two legislators in the House spoke against Section 14: Aime Wichtendahl (D-Linn), Iowa’s only transgender legislator, and Elinor Levin (D-Johnson), the only other openly queer legislator. While seeing solidarity between queer lawmakers is heartening, it was devastating to see so little action taken to fight this bill. We’ve seen time and time again that the majority of Iowa’s Democrats would rather play meek patsies to oppression than take any real risk, or use any sort of legislative strategy to fight back. Having to watch the few queer people that have a voice in the legislature try to overcome the rot at the heart of their party to argue for their lives and wellbeing is maddening.
Wichtendahl was frank in her remarks, saying “when I last spoke on this issue, I mentioned that I transitioned to save my life.” She went on to share her own history with debilitating depression and suicidality before transitioning, the impact it had on her family, and how having the chance to live as herself helped her turn her life around. “because I was able to receive gender affirming care, my life instantly got better,” she said. Wichtendahl went on to highlight the other attacks on healthcare from the legislature, including medicaid work requirements and religious freedom carve outs for insurance companies. “Your healthcare is very much in jeopardy, and don’t think for a minute that they will stop with the transgender community, because they won’t,” she said, adding that “the only real way to guarantee healthcare for anyone is to guarantee healthcare for everyone.”
Matt Windschitl (R-Harrison) interrupted Wichtendahl at one point, challenging the relevance of her remarks and accusing her of assuming Republican’s motivations in advancing Section 14. This felt like a ploy to prevent her having the full last word on the bill before voting. We’ve seen similar tactics used in Montana and Virginia to stop trans legislators from speaking in defense of their own lives and wellbeing.
Elinor Levin, who represents the “blue dot” of Iowa City, was brief, imploring her colleagues to talk to the trans people who would be hurt by the bill, listen to their experiences, and see how vital and lifesaving gender affirming care can be.
The bill’s floor manager Ann Meyer (R-Webster), in her closing remarks, denied that gender affirming care is even really healthcare. “The treatment that will be provided for gender dysphoria is behavioral health treatment” she said, gesturing to Rep. Wichtendahl, “I’ve heard psychological issues surrounding what might happen if someone is denied this treatment, and i will say, if someone is in mental distress, if someone is suicidal, the treatment for those issues is not surgery, is not hormone treatment, it’s behavioral health.”
Webster then went on to talk about the funding gaps in her own bill, suggesting that the money Iowa would save by cutting gender affirming care - which by her own admission amounted to only ~$2.5 million over the last decade - could be used to plug a multi-million dollar hole in funding for pediatric cancer research.
This is, accidentally, a concise summary of the conservative position: gender dysphoria isn’t real, you aren’t worth caring for unless you try to kill yourself, and even then we should force you into conversion therapy. There is a trans woman standing right in front of her, telling her that healthcare made her life worth living, and Webster simply refuses to listen. Erasing her colleague isn’t enough for Webster though, she also has to scapegoat trans people for an imagined host of funding issues that her own policies caused, just to score a sound byte for her eventual re-election campaign.
The bill passed the house 63-28.
Across the rotunda in the Senate, only one legislator, Molly Donahue (D-Marion), spoke out against Section 14, though she did a respectable job. Donahue was passionate, calling the bill “cruel” and “inhumane” while pointing out the nakedly unconstitutional discrimination at its root. “... That is a violation of equal protection, plain and simple. That is discriminatory. It is harmful and that is unconstitutional under the equal protections clause of our state constitution, something that the Iowa courts and others across the nation have already repeatedly affirmed” she said, pointing to her ability to get a hysterectomy while a trans person could not.
The Senate Republicans were initially a bit shaken by Donahue’s remarks, voting to defer the bill immediately after she spoke, but they ultimately came back and voted to pass HF 1049 31-15.
Iowa joins a number of other states, most notably Florida, Arkansas, and Texas, in this kind of structural discrimination. There are ongoing legal challenges to every medicaid care ban in the country right now, but policy and position changes at the Justice Department following Trump’s inauguration threaten the future of all of those challenges, especially as the prospect of a United States v. Skrmetti decision looms in the coming months.
Section 14 goes into effect on July 1st, 45 days from now, on the same day we lose our civil rights protections.
So, what now?
A non-exhaustive list of what to do now:
If you are on Medicaid you need to try to make your appointments and get your refills now. You will not be fully removed from Medicaid, but expect access to things like blood work for your HRT, regular appointments with your prescribing doctor, and potentially your scripts themselves to go away, or at minimum become more difficult. Try contacting your care providers every day until they do something. Some LGBT clinics in the state are prioritizing Medicaid patients in their scheduling and operations in advance of this bill, take advantage of that if you can. If possible, talk to your doctor about updating your diagnosis from “Gender Dysphoria” to “Endocrine Disorder” or “Hormonal Imbalance.” You have to advocate firmly for what you need, and stand your ground if you are challenged by uncooperative providers.
Reach out to the Iowa Trans Mutual Aid Fund. ITMAF exists to give direct aid to community members in need, and can help you cover the costs of HRT without insurance. They have a simple intake process that opens at the beginning of every month, and distribute funds directly to you to pay your prescription costs. They’ve helped hundreds of Iowans, including me, who have struggled with accessing and affording our care.
Autonomy Iowa City is a bodily autonomy action group that is stepping up to support our community’s immediate care needs. If you are impacted by Section 14 and are losing access to your HRT, reach out to them for support with accessing care.
Look for local mutual aid networks like Des Moines Mutual Aid, Iowa City Mutual Aid, and Fairfield Mutual Aid that are trying to support their community members in emergency circumstances.
Unionize. The best defense against these attacks is organized and coordinated labor. Your union can look to ensure trans healthcare is part of your insurance, and can take meaningful actions like labor stoppages and strikes to get power back in the hands of working people.
If you are an ally to our community, you have some additional steps:
First, make sure the trans people in your life and your community are supported. Reach out and check in with your loved ones to see what support they need, and do what you can to help. This could be as little as cooking a meal or offering emotional support - every trans person in Iowa has just been thrown into an ocean of uncertainty and anxiety about our futures and our access to the care that makes our lives whole - or as much as helping them cover the uninsured costs of their medical care. Everything you can do to help you do, from now on.
Second, donate to the Iowa Trans Mutual Aid Fund. They are a registered 501c3 that directly supports trans people in Iowa who are asking for help meeting their needs, whether that’s affording their HRT, covering co-pays for surgery, purchasing necessary clothing like binders and gaffs, or covering transportation to access their care in the first place. ITMAF is all volunteer run, and their only overhead is the cost of their accountant. ITMAF is the best way to help get direct aid into the community, especially if you are outside of Iowa. The vast majority of the money ITMAF distributes comes from in-community donations and in-community fundraisers, trans people giving back what little bits they can when they can. In order to meet the coming shock of need, ITMAF needs more support.
Third, show up. Go to protests. Go to city council meetings. Be loud. Be on the front lines of this fight with us. Trans people have to take on huge risks advocating for our rights and our lives every single day, we need our allies to fight just as hard.
And finally, LISTEN TO TRANS PEOPLE. We are the experts on our lives, our needs, and our healthcare. Period.
These are all things that the trans community already does. Our community has been doing them for decades to help each other survive. If you are really an ally, you have to join in that effort too.
This is my first article on this new substack, which i’ve thought about starting for some time. Many members of the trans community in Iowa, myself included, have felt abandoned and forgotten by media and legal resources, which are often directed either to larger states, or states where liberal organizations feel they have a better chance of winning. I wanted to try to do *something,* to say *something,* to do what I can to make sure that our community in Iowa is at least informed and given proper context for everything that’s happening.
The next post on this page, barring any other drastic Iowa news, will be an essay about dealing with depression post-transition, and the ways cis supremacy impacts our views of ourselves and our lives. It’s a piece I've been working on to some degree for a while, and I'm excited to share it.